Ovarian cancer, hereditary and otherwise
Ovarian cancer is the fifth most common cancer affecting women in Sri Lanka. Not all ovarian cysts or lumps are cancer, and not all ovarian cancers are the same. The most common form of ovarian cancer is the aggressive ‘high grade serous cancer’ (medical term: high grade serous carcinoma), which accounts for the majority of cases.
However, there are other types of ovarian cancer, including those which are a rare complication of endometriosis, a common benign condition that affects up to 1 in 10 women. It is also important to remember that cancers from other parts of the body, for example breast and bowel cancer, may spread to the ovary.
Symptoms and signs
The more aggressive forms of ovarian cancer often only become symptomatic once the tumour has spread beyond the ovaries to other parts of the body, which we refer to as ‘advanced stage’ disease. Common symptoms include bloating, fatigue, feeling full quickly after eating and having to urinate frequently, however these symptoms may also be caused by less serious conditions. Ovaries are deep seated organs in the body, so a ‘lump’ is not readily felt until it is large. Unlike cervical cancer and breast cancer, there are no established techniques to screen for early ovarian cancer. Any of these may result in a delayed diagnosis, which would inevitably also delay the start of treatment.
Diagnosis
Although imaging techniques such as ultrasound, CT, PET/CT and MRI scans provide useful information on the characteristics and spread of a tumour, the only way to determine the specific cancer-type is for a pathologist to examine a sample (biopsy) of tumour. The aggressive ‘high grade serous’ cancer has often spread beyond the ovary before it is detected, in which case the biopsy is obtained from an accessible site of disease (often the ‘omentum’, a fatty layer in the abdomen) targeted with the help of a scan. However, if the tumour is confined to the ovary, then specific diagnosis is often made at or after surgery, following examination of the ovarian tumour.
Treatment
The two main treatments for ovarian cancer are surgery and chemotherapy. The type and extent of surgery and the need for chemotherapy would depend on the tumour type and whether it is confined to the ovary or not. The aim of surgery, particularly in the case of the aggressive ‘high grade serous cancer’ (which has often spread to other sites), is to remove as much of the tumour as possible and therefore only an experienced specialist gynaecological cancer surgeon should do this, to ensure the best possible outcome for the patient.
Chemotherapy follows surgery, but sometimes it is administered with the aim of shrinking the tumour before surgery and often resumed after surgery. In many patients with advanced stage disease, chemotherapy provides disease free periods (remissions) of varying duration, but the cancer may return (relapse) needing further chemotherapy.
Novel treatments that attack the cancer in other ways have recently been approved and are available for selected patients in certain countries. One such agent attacks blood vessels that feed the tumour. Another is the category of PARP inhibitors, a type of targeted therapy that prevents the repair of damaged DNA in the cancer cells. Patients continue to receive such treatments for a long period after completing chemotherapy i.e. maintenance therapy.
The specialist cancer physician and surgeon work closely together to come up with a treatment plan that would work best for each individual patient.
How to prevent
hereditary ovarian cancer
In a proportion of women with high grade serous cancer, the tumour is hereditary.The is due to inherited abnormalities affecting specific genes that are involved in repairing damaged DNA, making them more susceptible to developing breast and ovarian cancers. The commonly affected genes are the BRCA genes (BRCA1 or BRCA2). If there is a family history of breast and/or ovarian cancer, seek medical advice regarding genetic testing, which can be done via a blood test. Once detected, carriers of the abnormal gene can then opt to have their ovaries and fallopian tubes removed before the cancer develops.
It is important to note that although regarded as ‘ovarian cancer’, we now know that ‘high grade serous cancer’ starts in the fallopian tube – the tubal structure that is attached to the ovary, the site where fertilisation of the egg by the sperm takes place. If only the ovaries are removed, the woman will continue to be at risk of developing the cancer, and therefore it is crucial that both ovaries and fallopian tubes are removed.
(The writer is a Consultant Histopathologist andSpecialist Haematopathologist and Gynaecological Pathologist attached to the Royal Marsden Hospital, London, UK)
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